Meeting halfway

Those of us focused on health IT are spending a lot of time and energy on bringing the technology to where the patients are. Interoperability is crucial because patients get care in so many different places, and through Regional Extension Centers and other programs we're trying to get EHRs into the hands of small and independent practices at the far reaches of the health care delivery system, again, because that's where the patients are. Something like 80% of practices are small practices, and 90% of outpatient encounters are in those small practices.

I've been wondering recently about whether we're going through a Copernican revolution where the patients come to the IT rather than having us bring the IT to the patients. My own personal experience started my thinking on this. I used to get my care from a small practice primary care physician in Wellesley MA -- great guy, good doctor, gives 110% every day. But he didn't have an EHR (still doesn't) and it was basically my responsibility to get specialist records back to him to make sure that he had the whole picture of my care. I switched to Harvard Vanguard not only because they have an excellent EHR but because they are multi-specialty as well. When I need a specialist I no longer scour all of Boston for the best specialist -- I only look within the Harvard Vanguard system because I want to make sure that my records are kept on the same EHR. What I might be sacrificing on the quality of an individual specialist I'm more than gaining back in having all of my physicians reading from the same page (literally).

Since my Wellesley doctor couldn't solve the interoperability issue, I solved it myself by eliminating it. My wife gets her care at the Brigham, and I've increasingly seen her focus her decision-making in the same way -- she has eliminated the need for interoperability by limiting her choice of specialists to those who are on the Brigham's EHR.

Maybe this is just a family thing. But I started thinking otherwise after I heard a very interesting story yesterday on NPR and Kaiser Health News on consolidation of the health care delivery market, and in particular, the increasing share of outpatient physicians employed by hospitals. As the story reports, almost 20% of physicians work for hospitals today, but 50% of new physicians are taking jobs with hospitals. The looming prospect of Accountable Care Organizations' becoming the operational unit of health care delivery will put increasing pressure on hospitals and physicians to keep patients within their care delivery network. Changes in health plans that limit patient choice will also drive patients to stay in closed networks. All of these trends will increasingly funnel patients into health care delivery networks that also happen to be connected on IT networks.

There could certainly be many bad affects from such consolidation, such as higher oligopolistic prices, less customer choice, the demise of solo practices that are an iconic part of the American fabric, etc etc. But from a health information exchange perspective, it's only to the good if we can get more patients to meet us halfway on the road to interoperability.

George Clooney's heart's in the right place, but his head isn't

One of my favorite news sources, People magazine, is reporting that George Clooney thinks that the Palisades Medical Center should go easy on the 40 employees who illegally looked at his medical records (see George Clooney Addresses the Leak of His Medical Records). The employees have been suspended without pay for a month. While I love Mr. Clooney as an actor, and am very sympathetic with his politics, on this one I think his compassion has gotten the best of him.

Unauthorized disclosures of patient information happen all the time. Most of the time it's unintentional and no harm is done. With intentional disclosures, there is a temptation to tailor punishment to motive -- specifically, to separate cases where a person looks at a record "with malice" from cases where it's "without malice". That's clearly what's going on at Palisades, and implicitly, in Mr. Clooney's head. I assume that the punishment would be different if an employee was found to be stealing Clooney's identity, or looking for his address or phone number to stalk him.

As more health care institutions convert to electronic medical records, there is increasing concern about privacy protection, and most of that concern is understandable and well-placed. The enormous benefits that can come from greater use of EMRs will go unrealized if we adopt a cavalier attitude on technologies and policies related to patient privacy. Suspending workers without pay in this case strikes me as being unbelievably lenient. If I was a patient at Palisades Medical Center, I would switch immediately to an institution that has greater respect for the trust that I've placed in them as the custodian of my records.

Dress codes for doctors

Today's Boston Globe had a little snippet entitled "Hospitals ban ties, jewelry for doctors". Apparently, concern about infection control has led British hospitals to ban physicians from wearing ties, jewelry, and long sleeves.

I'm sure that there are valid reasons to do this from an infection control perspective. Most convincing to me, though, was the statement by the Department of Health: "Ties are rarely laundered but worn daily...They perform no beneficial function."

I wish that all government policy statements were as succinct and to-the-point.......

Thanks Ron

Today's Globe had a story about the departure of Ron Hollander from the Massachusetts Hospital Association. I don't know anything about the issues at MHA. I do know that as a member of the Massachusetts eHealth Collaborative Board of Directors and Executive Committee, Ron has been a tremendous booster and we have benefited greatly from his wisdom and enthusiasm. We're going to miss his presence, and we wish him all the best.

Thank you Ron.

All for one and one for all?

This week's Modern Healthcare has an interesting article speculating on whether single-vendor RHIOs, which are rare today, could become a dominant model in the future. They cite as examples Inland Northwest Health Services from Washington state (which is based on the Meditech platform), and EHR of Rhode Island, a physician consortium working with eClinicalWorks.

I think the point of the article is an interesting one, but the examples they cite essentially answer the question of whether this will be a dominant model -- I don't think it will. Both INHS and EHRRI are very ideosyncratic models. INHS has integrated nicely on the inpatient side, but have very little penetration in the ambulatory side, which is always the hardest. I'm not even sure that EHRRI really qualifies as a RHIO -- they're doing excellent work, and have a very good model, but they're really an EHR purchasing/service consortium, not a health exchange.

MAeHC does have a single-vendor RHIO (of sorts) in North Adams, where all physicians are using the same EHR vendor who is also creating the HIE solution (eClinicalWorks). It's not a true single vendor solution because the hospital is on Meditech. We are certainly seeing lots of benefits in terms of ease of interoperability and richer exchange, and managing a single vendor is much easier than the alternative (this is not a trivial issue -- it's a big deal). However, North Adams is also a very ideosyncratic community that may not be widely applicable.

The key here is what gets the highest adoption. Consumer choice theory and empirical research suggest that greater choice will yield higher demand, but too much choice is paralyzing and confusing and may undercut demand. (I can confirm the latter -- I always dread having to buy more toothpaste because of the entire row of options that my local CVS puts in front of me.) This is why MAeHC offered partipating physicians choice but from a set of pre-qualified vendors. Given that "analysis paralysis" is a big barrier to adoption for many practices, this seems to be a good compromise formula for getting high adoption.

There are few, if any, EHRs that are optimal for all types of practices, so going with a single vendor will shut out some participants in most cases. It's possible that a hospital can drive physicians to a single solution based on their hospital platform, but my experience with the ambulatory products offered by the hospital vendors is that they sacrifice a little on the features side but in return for high interoperability with the hospital. Given the trend toward hospitalists and looser affiliation of ambulatory docs with their local hospital, I suspect that fewer and fewer physicians will be willing to make this trade in the future.

Management tips for HIE development

The lead story of the business section of today's Times is about Dr. Herb Pardes, head of New York-Presbyterian Health System. Though it doesn't mention it in the article, he is also a co-founder and co-leader of the Markle Foundation's Connecting for Health Steering Group (full disclosure -- I'm a member of the Steering Group).

The article is an interesting look at the dynamics of the big academic hospital industry, the New York hospital scene, and Herb's management approach. A few things about this approach strike me as noteworthy and particularly applicable to the HIE world:

• Re-orient thinking from provider-centric to patient-centric
• Be attentive to organization cultures and leader personalities
• Manage with mix of gut instinct and strong business skills
• Bring national perspective to local decision-making

No wonder these principles apply to HIEs. New York-Presbyterian comprises a stunning 52 hospitals, SNFs (skilled nursing facilities), and specialty centers across 5 campuses -- much bigger than any HIE in the country today.